Healthcare Provider Details

I. General information

NPI: 1750048260
Provider Name (Legal Business Name): TATIANA ELOISA HUEZO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HARBOR DR STE 111
SAUSALITO CA
94965
US

IV. Provider business mailing address

3 HARBOR DR STE 111
SAUSALITO CA
94965
US

V. Phone/Fax

Practice location:
  • Phone: 415-683-2988
  • Fax: 415-683-2980
Mailing address:
  • Phone: 415-683-2988
  • Fax: 415-683-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95018460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: